Editing Trache-oesophageal fistula

* Any communication between the respiratory tract and oesophagus

== Pathogenesis (acquired) ==
** Tissue necrosis and breakdown of respiratory tract and oesophagus
** Most commonly upper third of oesophagus where the membransou wall of trachea lies adjacent

== Aetiology ==
** Acquired
*** Benign
**** Iatrogenic
***** Prolonged intubation - require surgical management
***** Intubation injuries
***** Tracheostomy tube placement
***** Oesophageal/laryngeal resection
***** Dilatation procedures/stenting
**** Infectious
***** Anything that causes granulomatous inflammation - histoplasmosis, TB
**** Traumatic
***** Foreign body impaction/erosion
***** Caustic agent ingestion
***** Penetrating or blunt trauma to neck
*** Malignant - probably need palliation

== Presentation ==
** Chronic cough, exacerbated by PO intake
** Expectoration of food
** Recurrent LRTI (aspiration)
** Ventilated patient - inadequate tidal volume return, with gastric distension or a large gastric bubble on imaging. Increased secretions, aspiration of tube feeds from airway, difficulty maintaining seal with the cuff of endobronchial tube, persistent sepsis/pneumonia.

== Diagnosis ==
** Start with CXR: can see sequelae, including aspiration pneumonitis, dilated stomach/distal oesophagus.
** With recurrent aspiration pneumonitis, swallow evaluation may be beneficial to exclude oropharyngeal dysphagia
** Barium swallow - using dilute barium - especially for small fistulae (<1cm)
** Large fistulae best diagnosed with bronchoscopy/endoscopy, which also allows proper inspection of the airway, and biopsy if indicated

== Pre-op ==
** Treat and resolve pulmonary sepsis
** If mechanical ventilation can be weaned - do so - will minimise positive pressure within reconstructed trachea
** If patient is intubated, cuff should be below fistula, to prevent further contamination
** Optimise nutrition

== Treatment ==

=== Benign TOF are primarily managed with surgery ===
*** Anterior collar incision. May require sternotomy for access to distal trachea.
*** Single-stage is preferable when possible
*** Two-stage repair (tracheal resection and reconstruction with oesophageal diversion via cervical oesophagostomy, followed by interval primary oesophageal reconstruction)

=== Malignant TOF  are palliative ===
*** Surgery is not worthwhile in almost all cases - prognosis of weeks to months
*** Palliative stenting is effective for symptomatic fistulae
**** Individual or combination of stents placed across the fistula, to prevent passage of enteric contents
***** Barium swallow will be necessary in identifying anatomy
***** Optimise patient as much as possible, as for benign fistulae
***** Most malignant TOFs can be sealed using self-expanding metal or plastic covered or partially covered oesophageal stent
***** In some cases, tracheal stents may also be needed
***** Stents not recommended for stents at or above cricopharyngeus, because this will result in significant discomfort and dysphagia. In such cases, a definitive tracheostomy may be placed.
***** Fistulae to lobar or segmental bronchi are difficult to seal via bronchial stenting, so would be normally treated with oesophageal stent alone
***** Need minimal IV sedation and topical or nebulised anaesthetic
[[Category:UGIS]]
[[Category:Thoracics]]